Provider Demographics
NPI:1568799187
Name:GOMEZ, MARC AURELIO (LAC)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:AURELIO
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
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Mailing Address - Street 1:1131 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2061
Mailing Address - Country:US
Mailing Address - Phone:310-917-2200
Mailing Address - Fax:310-917-2204
Practice Address - Street 1:1131 WILSHIRE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2061
Practice Address - Country:US
Practice Address - Phone:310-917-2200
Practice Address - Fax:310-917-2204
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAAC 13305171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist